MedFlight of East Ky

EMT-BASIC STUDENT APPLICATION

Date:                                Birth Date:                            Sex(M/F)             

Name:                                                                                                        

               (Last Name)                       (First Name)             ( Middle Name)

Social Security Number:                                              

Address:                                                                                                    

City:                                                  State:                   Zip Code:                    

Home Phone:                          Work Phone:                         

Years of Education:      High School Diploma            GED          

Are you a member of a public service? If so name and contact information. _______________________________________________

E-mail Address ____________________________________________

Please answer the following questions. Failure to respond to these questions will result in this application not being processed.

1.         Have you ever been convicted of a felony?    Yes [  ]    No [  ]

2.         Have you ever been convicted of a misdemeanor or DUI? Yes [  ]   No [  ]

3.         Have you ever been certified as a First Responder, EMT, Paramedic in   

             Kentucky or any other state?  Yes [  ]   No [  ]

4.         Do you use drugs, alcohol or controlled substance to the extent that it may                        

            affect your ability to work as a EMT?  Yes [  ]  No [  ]

5.         Do you have a physical, mental or other disability that may affect your

            ability to work as a EMT? Yes [  ]  No [  ]

If you marked yes to any of the above questions please give an explanation below.                                                                                                                                                                                                                                                                                                                                                                                                                                                       

Signature of Applicant